March 21 (Monday)

Our work today was split into two teams, as Chris, wanting to see the poorer action area of rural Bangladesh, chose to take the bumpy four-hour ride down to ICDDR,B’s surveillance site in Matlab instead of spending another day in Dhaka. The rest of the squad began rounds in the morning with the amazing Drs. Chisti and Sharif. If yesterday was an awakening for us in the clinical severity of what we’d seen, however, today did not soften the blow. One of the babies with severe anemia and respiratory distress the day before was no longer there that morning. In his place was a new child, nearly comatose, with a triple malady of diarrhea, pneumonia, and neurological symptoms. Dr. Sharif gravely noted a differential diagnosis of tubercular meningitis and pulmonary TB. The little patient’s mother, an emaciated whisper of a woman, gravely looked on.

As for the children on bubble CPAP, we shadowed Ranjit, the respiratory technician, as he explained the device with Pam’s expert translation.

Photo: David Janka

First, the device is constructed by taking a standard pediatric nasal cannula with nasal prongs:

Photo: David Janka

Next, an infusion set is cut at the elastic.  

Photo: Pamela Pavkov

One end of the infusion set is attached to the cannula, the other goes to a shampoo bottle, which is filled with water.

The nasal cannula is plugged into central oxygen or an oxygen tank, and the bottle functions as a back-pressure regulator, whose pressure can be adjusted by varying the depth of water in the bottle. It’s quite an elegant device, considering it only costs a few hundred Bangladeshi Taka to make (less than $5 US) and saves babies’ lives.

It was wonderful seeing Ranjit educate the mothers of patients on how to help their children breathe easier, a measure that not only contributed to the care of the child, but made the moms feel less helpless and more empowered on doing something for their kids.

Our remaining time at ICDDR,B was then spent on an extensive hospital tour given by Mohammed Ullah. Our first stop was the outpatient ward, where children not in acute distress could be brought for supervised care. Mothers there watched with rapt attention there at a flash of yellow, a Shasto Shebeika (health worker, literally translated health woman) as she excitedly educated them on both the warning signs of severe illness as well as introductory nutrition.

There are few things in the world more exciting than health education.
I'm serious. (Photo: Pamela Pavkov)

Pam, after several minutes of writing down the ingredients suddenly exclaimed, “She’s making kichuri!”

“I hated kichuri when I was growing up, but my parents made me eat it all the time!”

We then passed through the emergency room, the short stay ward, and finally, the place of Muhammad Ullah’s “magic bullet”, the Nutrition Center. There, Pam was again amazed that the solution to childhood malnutrition was the boiled mix of rice, lentils, onion, spinach, potatoes, and oil from her childhood. The results were stunning, and the photos on the wall were proof of their efficacy.

Photo: Carey Lee

“The saddest part is that sometimes, it’s not due to a lack of food,” Mohammad-da sighed.

“Sometimes, young mothers just don’t know how much or how to properly feed their children.”

David should be a pediatrician when he grows up.
(Photo: Carey Lee)

After our own lentil-filled lunch, we headed to downtown Dhaka to check out a medical bazaar, a dimly lit collection of shops made yet dimmer by the far-too-common power outages in the city. Fumbling in the dark, the team split up to procure items possibly of use to us for the project. The bottle, infusion set, and nasal cannula were the easy part. Oxygen in Bangladesh, it appeared, was monopolized by the Bangladesh Oxygen Company (BOC), and O2 sources were going to be the priciest part of bubble CPAP.

"So the Dow Jones is down today, huh?"
(Photo: Pamela Pavkov)

The day finished with some hardcore brainstorming, as tomorrow will be our last at ICDDR,B.

March 20 (Sunday)

The cool relief of the night masked the inevitable this morning—wow, it’s hot in Bangladesh! We’re talking 95+F with 100000% humidity. I’m pretty sure that the minute I left the A/C in our room, I started dripping. Luckily, our trip to ICDDR,B was via closed van, and the comforts of Toyota brought us to the main gate of the hospital before any of us melted down.

Photo: Carey Lee

ICDDR,B was established in 1960 by an international consortium as a cholera research center and clinical site. Most people may know it best by the fact that ORS (oral rehydration solution) for use in severe dehydration was invented here (thereby saving millions of lives around the world). Today, the spirit of innovation continues, as the center leads the charge on the advancement of low-cost medical solutions for the developing world.

We were greeted at the gate by Musaid Kamruzzaman, Office Manager and MBA extraordinaire. He was to be our point person for all communications and logistics during the trip. Musaid then ushered us into a conference room where we met the true stars of the show: Dr. Pietroni, Medical Director of ICDDR,B; Muhammad Ullah, Chief of Nursing and member of the Ethics Review Board; Dr. Sharif, co-Investigator of the Bubble CPAP Device; Lisa Chambers, Nursing Education Consultant; and Khuku Moni, Charge Nurse of the ICU. After a round of introductions, we were set loose on a barrage of action items for the week: Dedicated needs-finding time with various members of the medical staff, rounds in the ICU, meetings with the engineering and maintenance staff, a trip to a private medical market, a visit to a government hospital (ICDDR,B is a private hospital), and a trip to LAMB hospital, a mission hospital in the rural northwest of the country. Whew!

Our day then launched immediately into morning rounds, and I was struck immediately with how much of our initial empathy-building in the States had only scratched the surface of the seriousness of the problem—ten-month old children less than half their expected weight, suffering from profound dehydration, chronic malnutrition, and a horde of infections were being hooked up to the existing bubble CPAP device, a shampoo bottle and infusion set cobbled together and plugged into a central oxygen line. It was just heartbreaking watching the mothers, many of whom had traveled hours by foot and bus to get to the hospital, stand vigil over their tubed-up babies, refusing to move lest their children’s labored breathing come to a stop in their absence.

Photo: David Janka

In this regard, ICDDR,B has been truly a champion of their struggles—the hospital charges absolutely nothing for any of their services, and even brings meals to the companions of their little patients. Despite the not-for-profit status of the hospital, it is widely considered to provide one of the highest standards of care in Bangladesh.

Dr. Chisti showing a mom how to read her baby's chest X-ray
(Photo: David Janka)

We were also lucky to catch a glimpse of Dr. Chisti, Primary Investigator and all-around miracle-worker. The father figure to our bubble CPAP device, he had studied in Australia, where he had heard of the technique and decided that it would be of great use at his hospital. Despite his great intelligence and legendary clinical skills, Dr. Chisti was still a very young physician, and with his perfect hair, charming charisma, and movie-star smile, had all the nurses and his junior colleagues standing at attention the minute he appeared. Several passes through the charts and percussions of chests later, he vanished back out into the hospital, called away to consult on an emergency that only he could solve.

The day concluded with meetings with Rahmat Ullah, Head of the Biomedical Engineering unit and Mizanur Rahman, Senior Manager of Infrastructure Service. Rahmat Ullah revealed to us that all the equipment in the labs and clinical wards of ICDDR,B are serviced by a single six-man team, most of whom learn their skills just once when the company technician arrives to install the device! Clearly our product was going to need both simplicity and locally-available parts. Despite the shortage in manpower, however, the squad is extremely resourceful. We toured their workshops and found them fixing everything from uninterruptible power supplies (UPS) to ventilators! It is clear that we’re working here with people who themselves are committed to extreme affordability and noble aspirations.

Photo: Pamela Pavkov

March 17-19 (Thursday- Saturday)

Leaving Stanford and its many obligations was a much tougher endeavor than I imagined. For one, I had a presentation on my research (unrelated to this project) the day before, which resulted in two consecutive all-nighters leading up to the trip. After a phone conference with my collaborator at 8PM, I raced back home to pack, since we were leaving campus at 10. Turns out I wasn’t the only one scraping out—Seth had just finished six finals (the last of which was the day of the flight) and Pam had left for India on Monday—the day after she finally got her visa.

A few celebratory beers later, we were on a 14-hour Cathay Pacific Flight CX173 to Hong Kong, our first stop on the way to Dhaka. International flights are my opportunity to catch up on all the movies I’ve missed, and it appears I’m not the only one—four members of our travel group watched “The King’s Speech”. Quote Seth: “You know you’re growing older when you can watch a movie that involves a bunch of people just talking for two hours and you think it’s exciting.”

Can we go to Panda Express next? (Photo: Chris Stivers)

We then landed in HK, where Carey left to spend the day with her grandmother and uncle, leaving the boys to explore town. We were lucky enough that my friend Shane, also a third-year medical student, was in town with his family. He took us on a full tour of the city, including a Buddhist temple, British WWII memorial, open-air market, and many of Hong Kong’s massive architectural wonders (a mix of classic East Asian, super-modern industrial, and English colonial). 
I particularly enjoyed our experience at an “authentic” dim sum place (which apparently doesn’t really exist in HK anymore since they’ve mostly been replaced by quieter sit-down places with menus). We battled our way into several cramped seats, and enjoyed timeless delicacies such as pork bun and chicken feet—at least I enjoyed the feet, since it freaks out my American friends.

After our nine hours as bona fide tourists were up, we took a quick hop on Dragon Air and at last landed in Dhaka. At that point, we had been traveling for 20 straight hours! Pam had a flight going through Calcutta to visit her family, so we waited at glorious Zia Dhaka International Airport for her, getting eaten alive by mosquitoes the size of small cats. Once she arrived, we were picked up by a member of ICDDR,B, and driven to our guest house. 


The representative asked an interesting request of us on the ride over: could we sing the US national anthem? The video won’t be posted here, but I think our overflowing enthusiasm for the red, white, and blue overcame how out of tune we were. Being Americans, we then demanded fair trade and that he sing the Bangladeshi national anthem. I think none of us were expecting what we heard: “Amar Shonar Bangla” (My Golden Bengal) was so warm and tender, a song which really conveyed how much love the writer, national poet Rabindranath Tagore, had for his homeland.

Listen here (and ignore the randomly scrolling pictures and text): http://www.youtube.com/watch?v=FIEzM7ZmfQk

This moment set the stage for the rest of the trip—realizing how different Americans and Bengalis are. The Star Spangled Banner represented the passionate, pugnacious can-do attitude of the US underdogs, while Amar Bangla embodied the peaceful, poetic understanding of our Bangladeshi hosts. 

March 16 - Chalo!

Nomoshkar, Asaalam! This is just a quick travel blog to help me record some thoughts on this trip to Bangladesh.

A little background on this whole experience:

I'm a third year medical student from Stanford University, currently taking a class at the Hasso Plattner Institute of Design, known more affectionately on campus as the d.School. The course, entitled Entrepreneurial Design for Extreme Affordability, brings together interdisciplinary teams of graduate students (from schools of business, medicine, engineering, product design, environmental studies, international studies, etc.) and challenges them to develop low-cost devices and services for use in the developing world. My particular team is working with the International Center for Diarrhoeal Diseases, Bangladesh (ICDDR,B) to build/improve a bubble CPAP (Continuous Positive Airway Pressure) device for use with pediatric pneumonia patients.

For some background, please see:

http://www.youtube.com/watch?v=FpTVfmTmEV0&feature=player_embedded#at=27

My travel partners for this trip include two members of my immediate team:

Pamela: MBA Carey: Mechanical Engineering

as well as the sole representative of another team developing a parallel CPAP device:

David: MD


and two students developing a cost-efficient infusion pump

Seth: MBA Chris: Mechanical Engineering


If you're for some reason following our journey, please feel free to comment here and learn more about our partner organizations at:


http://www.icddrb.org/
http://extreme.stanford.edu/
http://dschool.stanford.edu/